Completely Occlusive Portal Vein Thrombosis as a Predictor of Mortality in Acute Variceal Bleeding

Background Risk stratification plays a critical role in acute variceal bleeding (AVB) management, while portal vein thrombosis (PVT) has uncertain prognostic significance in AVB. Aim This study aimed to investigate the impact of PVT on the prognosis of patients with cirrhosis and AVB, with a particular focus on the influence of PVT severity stratification. Methods A retrospective analysis was conducted on 1389 cirrhotic patients with PVT ( n = 292, 21.1%) and without PVT ( n = 1096, 78.9%) admitted between 2016 and 2022 due to AVB. Patients were stratified based on PVT presence and severity according to the AASLD criteria. Propensity score matching was applied to balance baseline characteristics. The primary endpoint was 6‐week mortality. Results The overall 6‐week mortality was 8.6%. Patients with PVT had a similar risk of mortality compared with those without PVT (10.14% vs. 8.10%; HR 1.26, 95% CI 0.81–1.96, p = 0.306). However, complete occlusive PVT was associated with significantly higher 6‐week mortality compared to non‐PVT patients (35.3% vs. 8.1%; HR 5.61, 95% CI 2.61–11.90, p < 0.001). Transjugular intrahepatic portosystemic shunt (TIPS) could reduce the risk in these patients (0% vs. 44.4%; HR 0.22, 95% CI 0.05–0.97, p = 0.046). Conclusions Patients with completely occlusive PVT had a higher risk of 6‐week mortality after AVB. These findings highlight the importance of incorporating PVT severity into AVB risk stratification and support considering TIPS in high‐risk patients, although the benefit of preemptive TIPS needs further investigation.